Lim Hong-Gook, Lee Jeong Ryul, Kim Yong Jin
Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea.
Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea.
Ann Thorac Surg. 2017 Jul;104(1):197-204. doi: 10.1016/j.athoracsur.2016.11.033. Epub 2017 Apr 25.
Refractory atrial arrhythmias and hemodynamic abnormalities are responsible for significant morbidity and mortality after the Fontan operation. We evaluated the long-term feasibility, safety, and efficacy of prophylactic atrial arrhythmia surgery performed concomitantly with the lateral tunnel Fontan operation.
From 1997 August to 2003 December, 27 patients underwent a initial lateral tunnel Fontan with an interventional atrial incision and cryoablation from the atriotomy to the coronary sinus and right atrioventricular valve annulus. This novel surgical technique consists of (1) right atriotomy extending to the coronary sinus to block the slow rate conduction isthmus; (2) cryoablation between right atriotomy and right atrioventricular valve annulus; (3) baffling to avoid injury to the crista terminalis; and (4) use of a sandwich technique with closure of right atriotomy incorporating the Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ) patch to reduce atrial suture line.
There has been no early death after operation and one late death, which was not arrhythmic in etiology. At late follow-up of 15.2 ± 2.9 years (range, 5.5 to 18.0) after Fontan, spontaneous intraatrial reentrant tachycardia occurred in 1 patient, and inducible intraatrial reentrant tachycardia in 1 patient who required beta-blocker medication without ablation attempts. There was no evidence of early or late complications related to the interventional atrial incision and cryoablation. Four patients required late pacemaker implantation for sinus node dysfunction after Fontan operation.
The prophylactic arrhythmia surgery with our novel modification of the lateral tunnel Fontan procedure to reduce the development of intraatrial reentrant tachycardia was feasible and safe. Long-term follow-up results also demonstrated that this novel modification is effective for the prophylaxis of intraatrial reentrant tachycardia.
难治性房性心律失常和血流动力学异常是Fontan手术术后高发病率和死亡率的原因。我们评估了与侧隧道Fontan手术同时进行的预防性房性心律失常手术的长期可行性、安全性和疗效。
从1997年8月至2003年12月，27例患者接受了初次侧隧道Fontan手术，同时进行介入性心房切口并从心房切口至冠状窦和右房室瓣环进行冷冻消融。这种新颖的手术技术包括：（1）右心房切口延伸至冠状窦以阻断缓慢传导峡部；（2）在右心房切口与右房室瓣环之间进行冷冻消融；（3）构建挡板以避免损伤界嵴；（4）采用三明治技术，用Gore-Tex（W.L.Gore&Associates，弗拉格斯塔夫，亚利桑那州）补片封闭右心房切口以减少心房缝线。
术后无早期死亡病例，1例晚期死亡，其病因并非心律失常。在Fontan手术后15.2±2.9年（范围5.5至18.0年）的晚期随访中，1例患者发生了自发性房内折返性心动过速，1例患者可诱发房内折返性心动过速，该患者需要使用β受体阻滞剂治疗而未尝试消融。没有证据表明与介入性心房切口和冷冻消融相关的早期或晚期并发症。4例患者在Fontan手术后因窦房结功能障碍需要晚期植入起搏器。
采用我们对侧隧道Fontan手术的新颖改良进行预防性心律失常手术以减少房内折返性心动过速的发生是可行且安全的。长期随访结果也表明，这种新颖的改良对于预防房内折返性心动过速是有效的。
